Korean J Thorac Cardiovasc Surg 2014;47:174-177 ISSN: 2233-601X (Print)
□ Case Report □
http://dx.doi.org/10.5090/kjtcs.2014.47.2.174
ISSN: 2093-6516 (Online)
Endovascular Revascularization for the Obstruction after Patch Angioplasty in Buerger’s Disease Hee Jae Jun, M.D.
Surgical revascularization for patients with Buerger’s disease is possible only in a few cases, due to the diffuse segmental involvement and the lack of distal runoff vessels available for bypass surgery. We encountered a case of resting pain in the right foot, coldness with dysesthesia, and cyanosis on the right 1st toe. The patient was treated with an endovascular intervention after vein patch angioplasty failed due to an inflammatory reaction of Buerger’s disease. We suggest that an endovascular procedure can be an effective treatment, even in addition to more conservative and surgical management, in patients with Buerger’s disease and critical limb ischemia. Key words: 1. Thromboangiitis obliterans 2. Revascularization 3. Angioplasty
chial pressure index (ABI) was 0.6 on the right leg. As he
CASE REPORT
was a heavy smoker, the patient’s hands and feet were usuTotal tobacco cessation is the only treatment that improves
ally cold, and the symptoms became severe when he was ex-
the symptoms and reduces the risk of amputation in Bue-
posed to a cold environment. He was free of other diseases,
rger’s disease. Other forms of treatment are not well estab-
including autoimmune disease, hypercoagulable state, and dia-
lished or have unfavorable results. Surgical revascularization
betes mellitus. Hematological laboratory findings and renal
is often ineffective because the distal target vessels are often
function tests were normal. Computerized tomography (CT)
involved in this diffuse segmental disease. Calcium channel
angiography showed segmental obstructions of the below-knee
blockers, anticoagulants, thrombolytics, prostaglandin analogs,
popliteal artery, which showed intraluminal thrombosis, and
sympathectomy, adrenalectomy, spinal cord stimulators, omen-
in the posterior tibial artery. The anterior tibial artery was ob-
tal transfers, and stem cell treatment have all been tried with
structed (Fig. 1). We decided to operate because of the se-
limited success in decreasing rest pain and avoiding
verity of the symptoms and the short segmental obstruction
amputation. We report a case of an interventional endovas-
with thrombus. The wall of the popliteal artery had an adhe-
cular procedure for revascularization.
sion and had thickened. The intima of the popliteal artery had
A 28-year-old male had been suffering from acute right
also thickened due to inflammatory changes. We performed
foot pain at rest and coldness with dysesthesia, cyanosis on
endarterectomy and vein patch angioplasty of the obstructed
the right 1st toe, and claudication for 3 weeks. The ankle-bra-
popliteal artery with the greater saphenous vein. A Fogarty
Department of Thoracic and Cardiovascular Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine Received: December 5, 2013, Revised: January 5, 2014, Accepted: January 16, 2014 Corresponding author: Hee Jae Jun, Department of Thoracic and Cardiovascular Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, 875 Haeun-daero, Haeundae-gu, Busan 612-862, Korea (Tel) 82-51-797-3131 (Fax) 82-51-797-3101 (E-mail)
[email protected] C The Korean Society for Thoracic and Cardiovascular Surgery. 2014. All right reserved. CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Endovascular Revascularization in Buerger’s Disease
Fig. 1. (A) Computerized tomography (CT) angiography shows segmental obstructions of the below-knee right popliteal artery and posterior tibial artery (arrow). The anterior tibial artery is obstructed in this image. (B) CT angiography shows good patency of the segmental obstructions of the below-knee right popliteal artery and patch angioplasty of the right posterior tibial artery after surgery (arrow). catheter was not passed under the obstruction of the posterior
dural angiogram showed severe stenosis in the upper part of
tibial artery. However, the arteriotomy site was closed with
the vein patch angioplasty of the posterior tibial artery. The
patch angioplasty because of the occurrence of a large amount
possibility of stenosis and obstruction always exists in the
of back bleeding. After the first operation, the patient’s symp-
blood vessels of patients with Buerger’s disease due to in-
toms did not improve and the patient requested reoperation to
flammatory reactions. Angioplasty of the posterior tibial ar-
alleviate the symptoms. The blood vessel had surrounding co-
tery was performed using a balloon catheter (4–40 mm, Ever-
alescence with an inflammatory reaction. We performed vein
Cross; ev3 Endovascular Inc., Plymouth, MN, USA). Angiog-
patch angioplasty in the segmental obstruction of the posterior
raphy after this procedure demonstrated a good final angio-
tibial artery 2 weeks after the first operation. Because of the
graphic result and the absence of critical stenosis. Improved
thick intima and fibrosis, endarterectomy was not possible.
blood circulation was observed in the CT angiography per-
After the operation, the patient’s symptoms improved and he
formed after 1 year (Fig. 3). The patient recovered com-
was discharged on postoperative day 15. His ABI was 1.0.
pletely with no further complications or symptoms. This pa-
In the histopathological examination, segmentally resected
tient quit smoking from before the first operation until the
and serially sectioned popliteal arteries showed subacute
time of this report. For 2 months after the endovascular pro-
stages of Buerger’s disease. The lumen was near-totally or to-
cedure, warfarin was used. From after the first operation until
tally occluded by organized thrombi that presented as recanal-
the present, aspirin and clopidogrel (Plavix) have been used.
ized vessels. Remarkable chronic inflammatory cells such as lymphocytes and plasma cells were observed in the recanal-
DISCUSSION
ized vessel wall with less inflammation in the walls of the Buerger’s disease is defined as a nonatherosclerotic seg-
blood vessels. The symptoms recurred, and the patient was re-hospitalized
mental disease that is characterized by occlusive, in-
after 3 months. CT angiography showed diffuse posterior ti-
flammatory, and thrombotic changes. Several different criteria,
bial artery obstructions in the patch angioplasty of the poste-
such as those suggested by Shionoya [1] and Olin [2], have
rior tibial artery in the upper direction (Fig. 2). A pre-proce-
been proposed for the diagnosis of Buerger’s disease. Our
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Hee Jae Jun
Fig. 2. Computerized tomography angiography shows diffuse obstruction in an anastomosis site of patch angioplasty of the right posterior tibial artery (arrow).
Fig. 3. Post-interventional computerized tomography angiography shows improved blood circulation in the right posterior tibial artery (arrow).
case met all of the diagnostic criteria. Typical angiographic
amputations [4,5]. The risk of amputation is highly correlated
findings were distal vessel disease with no presence of arte-
with continuing to smoke; the amputation rate varies from
rial wall calcification and the development of a rich typical
42% to 5% at the Cleveland Clinic Foundation according to
subcutaneous network of collaterals, usually referred to as
tobacco use [3]. At the end of a 5-year follow-up, the median
corkscrew collaterals [3]. Tobacco use, in any of its forms,
prevalence of amputation in patients with Buerger’s disease,
plays a central role in the pathogenesis and progression of
based on the most recently reported series, is reported to be
the condition [4]. Clinical presentation usually begins with is-
as high as 24.4% for minor amputations and 8.6% for major
chemia of the distal small arteries and veins of the legs,
amputations, for a total amputation rate of 33% for patients
arms, feet, and hands, which is manifested by claudication of
treated conservatively [3].
the corresponding extremities [2]. Progression of the disease
Surgical revascularization for patients with Buerger’s dis-
is typically characterized by calf claudication and, eventually,
ease is possible only in a few cases, as a result of diffuse
ischemic pain at rest. Ischemic ulcerations on the toes, feet,
distal involvement with no distal runoff vessels available for
or fingers may develop. Superinfection often occurs, and the
bypass surgery [6,7]. Consequently, surgical procedures are
lesions progress toward necrosis and distal gangrene. The
technically challenging, with very low feasibility and patency
prognosis for patients with Buerger’s disease with respect to
rates.
limb loss is significantly worse than that for patients with ei-
Endovascular treatment for Buerger’s disease is not gen-
ther atherosclerosis or the various forms of necrotizing im-
erally reported in the medical literature as either feasible or
mune arteritis [2,4]. At present, the only proven strategy to
effective. Graziani et al. [8] reported that an endovascular
prevent the progression of the disease and avoid amputation,
procedure is safe, technically feasible, and effective, in-
in some cases, is the complete discontinuation of cigarette
dependent of the continued or non-use of tobacco, which
smoking or any other use of tobacco in any form [5].
leads us to argue that the procedure alone achieved these
Nevertheless, many patients continue to have a very poor
high rates of clinical success, the decreased rates of amputa-
quality of life owing to the persistence of symptoms such as
tion, and the maintenance of clinical improvement during
intermittent claudication, Raynaud’s phenomenon, or even
midterm follow-up periods. Although the physiopathology of
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Endovascular Revascularization in Buerger’s Disease
the disease is characterized by the presence of inflammation
reported.
arteritis and associated thrombosis, this did not preclude or affect the results of the primary angioplasty of the treated
REFERENCES
lesions. In our case, the patient was suspected of having a subacute form of Buerger’s disease on the basis of the microscopic findings. It seems that inflammatory changes in blood vessel obstruction were in progress after the patient underwent patch angioplasty of the segmental obstruction. We resolved this by endovascular intervention, and we have been observing the patient’s progress for about a year, but no strictures or other abnormalities have been found. Finally, although tobacco cessation is one of the most important steps for a significant reduction in disease progression, we believe that an endovascular procedure can be an effective treatment, even in addition to more conservative and surgical management, in patients with Buerger’s disease and critical limb ischemia.
CONFLICT OF INTEREST
1. Shionoya S. Diagnostic criteria of Buerger’s disease. Int J Cardiol 1998;66 Suppl 1:S243-5. 2. Olin JW. Thromboangiitis obliterans (Buerger’s disease). N Engl J Med 2000;343:864-9. 3. Puechal X, Fiessinger JN. Thromboangiitis obliterans or Buerger’s disease: challenges for the rheumatologist. Rheumatology (Oxford) 2007;46:192-9. 4. Arkkila PE. Thromboangiitis obliterans (Buerger’s disease). Orphanet J Rare Dis 2006;1:14. 5. Corelli F. Buerger’s disease: cigarette smoker disease may always be cured by medical therapy alone: uselessness of operative treatment. J Cardiovasc Surg (Torino) 1973;14: 28-36. 6. Dilege S, Aksoy M, Kayabali M, Genc FA, Senturk M, Baktiroglu S. Vascular reconstruction in Buerger’s disease: is it feasible? Surg Today 2002;32:1042-7. 7. Bozkurt AK, Besirli K, Koksal C, et al. Surgical treatment of Buerger’s disease. Vascular 2004;12:192-7. 8. Graziani L, Morelli L, Parini F, et al. Clinical outcome after extended endovascular recanalization in Buerger’s disease in 20 consecutive cases. Ann Vasc Surg 2012;26:387-95.
No potential conflict of interest relevant to this article was
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